Introduction: The aim of this paper is to introduce the structure of pain management practice
in the USA to medical professionals in Russia. The structure, organization, and educational requirements
established for pain management specialists in the USA will be discussed. The curriculum of a
pain fellowship will also be reviewed. Some important terminology as well as problems in modern
pain practice will also be addressed.

Structure: The physician specializing in pain medicine often serves as an educator and
consultant to other physicians on the intricacies of helping patients with pain. Primarily, pain
medicine physicians provide direct care to patients by evaluating, diagnosing, and treating their
various conditions. Treatment includes prescribing medication and rehabilitative services, performing
pain-relieving procedures, and counseling patients and their families. Physicians specializing
in pain medicine provide care in a variety of settings and are able to treat the entire range
of painful disorders encountered in the delivery of quality health care.

Historically, the pain service in the USA is based within the Department of Anesthesiology
or the Department of Neurology.

Anesthesiology based pain services can have two divisions: an Acute pain service (APS)
and a Chronic pain service (CPS). Large pediatric hospitals, pediatric oncology centers and hospitals,
performing big volumes of complicated pediatric surgery often also run a Pediatric pain service
(PedsP). These pain services usually consists of members of the anesthesiology department taking
care of acute postoperative pain and complicated chronic pain problems. The active role of anesthesiologists
in the operation of the pain service is justified by their knowledge of the physiology, pharmacology,
and the anatomic pathways involved in the modulation of pain. Management by an anesthesia pain
service not only includes pharmacological approaches, psychological interventions, referral for
physiotherapy, but also invasive interventional procedures. These include epidural steroid injections,
peripheral blocks (sympathetic, stellate ganglion, superior hypogastric, ganglion of impar, paravertebral-intercostal),
placement of the intrathecal delivery systems (implantable pumps) or chronic epidural catheters.

Neurology based pain services have multiple referral systems. Patients seen by a neurology
based pain service are recruited from different medical services: neurology, medicine, oncology,
and headache clinics. Services offered by neurology pain may include pharmacological approaches,
psychological approaches, counseling, but not invasive interventions. In addition, they have grown
to include under their auspices care of the dying cancer patient. This recent trend in the USA
is the development of a Pain and Palliative Care service, which is predominantly composed
of members of the neurology team. The creation of the palliative care system brought a new prospective
and philosophy to medicine about the dying patient. Here relief of pain and suffering for the
patient and their family are key issues in management. One of the central tenets of the palliative
care movement, now almost a decade old, is that dying is a natural process, not something to be
postponed by unnecessarily aggressive therapies or hastened by deadly potions. Palliative care
neither lengthens life nor shortens it. Rather, it attempts to make whatever time the patient
has left as comfortable and as dignified as possible. This kind of care also supports family members,
so that they are strengthened by the whole end-of-life process rather than hurt by it.

As may be appreciated, functions of the anesthesia and neurology based programs
are very similar with interventional pain management being the primary responsibility of the anesthesiologist.
It is very beneficial to have a multidisciplinary team established, where members of the neurology,
anesthesiology, psychiatry, rehabilitation and social service departments care in conjunction
for patients. This model is believed to bring the most benefit to the patient and leading groups
in the USA follow such a multidisciplinary approach.

Organization: Medical providers in the USA can be divided into three general
categories: University Centers, Community Hospitals, and solo practitioners. Presently, all University
Hospitals have established pain programs. Community hospitals around the country are operating
pain clinics or in the process of the creating ones. The recent interest of the medical and civilian
community in the question of undertreated pain has initiated many legal actions that have forced
community hospitals to organize pain services . Solo practitioners involved in the operation of
pain clinics are mostly anesthesiologists unless the clinic is following a multidisciplinary pathway.
It is still an searching area for an optimal functioning model.

Educational requirements: At present, the subspecialty of Pain management
in the USA includes professionals from three different fields: neurology, anesthesiology and rehabilitation
medicine

Neurology:

1 year of internship,

3 years of neurology training,

1 year of clinical fellowship in pain management in a neurology based program,

board examination in neurology,

board examination in pain management (written)

Anesthesiology:

1year of internship,

3years of anesthesiology training,

1 year of clinical fellowship in pain management in an anesthesia based program,

written examination in anesthesiology,

oral examination in anesthesiology,

examination in the pain management (written)

A good place to review information on anesthesia based pain fellowships is the web-site of the
American Society of Regional Anesthesia http://www.asra.com

Rehabilitation:

1 year of internship,

3 years of rehabilitation medicine,

1 year of clinical fellowship in the pain management in a neurology based

programboard examination in rehab. medicine,

board exam in pain (written)

In 1998, the American Board of Anesthesiology (ABA) issued its first subspecialty pain certificates
to qualified ABA diplomats. In 1998, ABA supported a joint proposal by the American Board of Physical
Medicine and Rehabilitation (ABPMR) and the American Board of Psychiatry and Neurology (ABPN)
that allowed these boards to offer subspecialty certification in pain. With the single examination
process, a joint committee was formed with representatives from each specialty. However, the ABA
determines the passing standards for the examination[1]. Since, the ABA first offered the pain
management examination in 1993, 2243 diplomates have passed the examination.

There are currently 97 anesthesia based accredited pain management programs in the USA; each
program offers between 1-8 training positions. The number of physicians seeking fellowship training
in pain management has steadily grown over the past decade. There were 260 fellows training in
accredited pain management programs during the 1998-99 academic year[2]. There are several anesthesiology
programs that offer fellowships to neurologists. Recent changes in the field highlight the importance
of establishing an integrative approach and good communication among different specialties involved
in the field of pain management.

The international association for the study of pain publishes the core curriculum for professional
education in pain and ABA is following this direction in conducting board examination[3].

Training in the
subspecialty of pain management: In order to provide a trainee with an adequate exposure to different
pain syndromes and equip him/her with the ability to manage a variety of clinical pain scenarios
enrollment in a fellowship program is a must. A fellowship program exposes participants to both
acute and chronic pain patients. The introduction to an acute pain service in the hospital can
serve as an initiating step in the formation of the pain specialist[4]. Memorial Sloan Kettering
Cancer Center in New York has an active surgical program which requires continuos attention form
the pain service. We provide surgical patients with acute postoperative pain control for the duration
of their postoperative period. If, after discharge from the hospital, a patient still requires
more than an average amount of pain medication we continue management in our “chronic pain clinic”.
The most common means of postoperative pain control in the USA is through a patient controlled
analgesia (PCA) machine[see picture]. PCA is a method of delivery of opioids via the intravenous
route using a computerized infusion system (pump). Our pumps are able to deliver medication continuously
and provide additional boluses of the medication upon the patient pushing a button. We limit amount
of medication patient is able to receive via computerised lock. We evaluate patients postoperatively,
assess analgesic requirements and place an order for a PCA. Presently there are six opioids that
we use for intravenous PCA. These are: Morphine, Hydromorphone, Fentanyl, Methadone, Oxymorphone
and Levorphanol. The selection criteria for each opioid are generally formalized but are not limited
by strict regulations, in part to fulfill the educational objectives of our program. Every day,
the pain team has a formal report where we discuss all the patients, construct a plan and receive
information from the person on call the previous night. After the report is completed, the pain
team rounds on all patients adjusting medications according to the patient’s condition. We also
manage all side effects that may arise from the drugs we prescribe.

Due to the high volume of complex surgeries performed at our center and the large number of thoracotomies
performed, part of the acute pain service experience is an intense exposure to infusions via thoracic
epidural catheters. We place approximately 4-15 epidural catheters each day. Usually we manage
10-15 epidural catheters per day. A choice of 3 opioids (morphine, hydromorphone or fentanyl)
and 2 local anesthetic agents (bupivacaine or lidocaine) as well as clonidine are employed in
our epidural infusions. Since epidural analgesia is delivered via the pump with patients partially
controlling the device we call it EPI-PCA, which stands for epidural patient controlled analgesia.
We deliver medication via a continuos infusion, and for additional analgesia, the patient is able
to receive a rescue dose every 20-30 minutes, pushing a special initiating button. Also, all side
effects from epidural infusions, such as nausea, sedation, numbness from local anesthetics, inadequate
pain relief etc. are managed accordingly by our team.

Care for Cancer patients (which our center specializes in) is full of nuances due to the nature
of the disease. Many patients are suffering from advanced neoplastic processes which require extraordinary
measures to control pain. Multiple side effects from the therapy also contribute to the challenges
of the patient’s day to day care . On many occasions growing tumors expand in space limited by
body structures, such as the pelvic cavity. Due to limited surrounding space tumor rapidly invade
tissues, elements of the peripheral nervous system, fracturing bones and penetrating to the vertebral
bodies, epidural space and spinal canal. Compression of the nervous plexuses or vertebral compression
fractures are among most dramatic pain experiences in our practice. Due to limitation of the efficacy
of the opioids in the treatment of the “compression syndromes” we are forced to try invasive modalities
in an attempt to control a patient’s pain. We always start with a trial of conservative pharmacological
therapy. Nevertheless, there are situations when inadequate pain control or severe side effects
force us to abandon conservative routes and proceed with invasive treatments. We place chronic
epidural catheters with externalized pumps, intrathecal catheter with internalized pumps and recently
we started to employ externalized intrathecal infusions for pain syndromes resistant to conventional
therapy. We also perform epidural neurolysis with phenol for pain due to esophageal malignancies,
paravertebral neurolytic blocks with alcohol for pain from rib’s metastasis , neurolytic celiac
plexus blocks for pancreatic cancer and ganglion of Impar block for resistant pelvic pain.

Pain Clinic: Patients are referred to the pain clinic by surgical or medical services.
In addition, patients may choose to refer themselves to a pain clinic. Patients of all ages can
be referred to the pain treatment clinic: those suffering from acute or chronic pain, patients
suffering from post-operative or post traumatic pain, or any type of chronic pain whether the
source is malignant or non-malignant. Here, a thorough and formal evaluation of a patient occurs
through a history , physical and detailed examination of laboratory and imaging. Although some
syndromes are diagnosed by history and physical, most require the use of some form of imaging,
such as CT Scans and Magnetic Resonance Imaging. While there, the pain is defined and appropriate
therapies are planned. Patients call the clinic again in 3-7 days to update the physicians on
the effectiveness of their treatments and any side effects. Patients are seen in the clinic approximately
every month at which time medications are adjusted. Effective therapy requires the patient to
be an active member of the treatment team as well as the patient’s referring physician.

Problems and future trends: As with any newly developing field, pain management has it
is own internal and external problems. Some of these include:

By not being a primary care specialty, pain management is not a primary reason patient’s coming
to a hospital. Rather, it is an adjunct to the treatment of their disease, even though it may
dominate their life more than the disease itself.

The Pain management specialist can not fully implement his/her plans without the approval and
support of the referring physician.

Often, we see patients late in the chain of health care professionals, at a time when our options
are limited.

Our colleagues have a limited knowledge regarding our potential and our abilities to take care
of complicated pain issues. This is especially true in the area of interventional pain management,
where the referring specialties should be aware of the benefits of the procedures we perform.

Fear of drug addiction is a major limiting factor for many patients seeking treatment.

Professionals from a variety of the medical fields and paraclinical personal are trying to get
involved in pain management , including attempts to get certification in interventional procedures.

There is a need for future developments of standards in the training and conduction of randomized
controlled trials to assess the efficacy and the safety of the therapies we offer.

Conclusions: We described the general organization, functions and legal aspects of pain
management in the USA. We hope , that issues we introduced will be of some benefit to our Russian
colleges. If it generates any interest , please, do not hesitate to contact us atsmironov@aol.com
for D. Mironov andmalhotrv@mskcc.org for
T. Malhotra. We appreciate your attention.

Literature :

A. Still, Pain Medicine-untangling the Web of Certification, American Society of Anesthesiologist;
Newsletter, November 2000,p8-9

J. Rathmell, Are we training too many pain specialists, American Society of Anesthesiologist;
Newsletter, November 2000, p10-11.

International Association for the Study of Pain, Core Curriculum for Professional Education
in Pain,1998